Tasmanian example leading way
ETerry J. Hannan
ARLY this year the US Food and Drug Administration issued a warning confirming physicians have been inappropriately prescribing opioids and benzodiazepines.
This has been associated with adverse outcomes as well as a precipitous increase in heroin and fentanyl overdoses. (“FDA requires new warnings on combined opioid, benzodiazepine use”: www.aafp.org/news/health-ofthe-public/20160907opioidbenzos.html).
In Australia, the media is awash with discussions (informed, uninformed, outright ignorant and hearsay) about the use of prescribed addictive medications within the community.
It can be stated that there is very little social cohesion on this topic and with this comes the political and social pressures to enhance their use when the actual evidence is saying the opposite.
William Osler stated that “morphine (the active ingredient of all narcotics) is God’s own medicine”. Sadly the use of these narcotic drugs and the benzodiazepines (Mother’s Little Helper) is causing immense social and clinical harm.
We aim to provide a rational and critical look at some of the issues surrounding the use of these agents. Much of the data presented is from the US but is also supported by emerging Australian data.
Some background history is justified here.
In the 1990s, pain was designated as the “fifth vital sign,” and physicians were urged to reduce pain with opioids. Pharmaceutical companies were also heavily marketing opioids to physicians. Since 1999, opioid prescriptions in the United
Keith Rice
States and in Australia have more than quadrupled, despite no increases in reported pain. Opioid abuse and overdosing increase the demand on and expand health costs.
With this medical and social dilemma it is justified in seeking answers to why there is so much prescribing of these drugs.
Is pain education adequate? Evidence would indicate no.
Is the current health care delivery system suited to the management of chronic pain? No.
What are the legal implications to the prescribers of maintaining inappropriate opioid and benzodiazepine prescribing when the science indicates otherwise?
Evidence shows the clinical decision support systems — paper or electronic — are severely inadequate to manage these clinical issues.
How do we best treat individuals struggling with opioid use disorder while there is still significant stigma surrounding addiction and hindering progress?
Substance use disorders must be approached as a chronic disease, not as a moral failing. The solutions to this complex epidemic will require collaboration across multiple stakeholders, including primary care providers, policymakers and law enforcement.
Why do Western (economically developed) social structures have this abuse of opiate prescription drug problem?
There is no clear answer to such a complex question, however some background may inspire further debate.
Tasmania began growing poppies in about 1965. From that time up until now it has become a major global producer of opiate-based pain management material.
With the application of sophisticated science and technology to an agricultural crop, Tasmania and to a much smaller degree several mainland states now produce about 50 per cent of the global demand for narcotic raw material (NRM), which is the starter base for morphine, codeine, oxycodone, oripavine and noscapine.
The growing and processing of NRM in Australia is highly regulated locally, nationally and internationally starting with the United Nations Commission on Narcotic Drugs (UNCND). Much of the work of the UNCND is administered by the International Narcotic Control Board (INCB).
This illustrates “the limitation of the use of drugs to medical and scientific purposes is a fundamental principle that lies at the heart of the international drug control framework”, para 222, INCB Report 2016.
Australian farmers are deeply concerned that from their perspective they grow in a highly regulated structure yet when their original product reaches its final destination as a dosage or tablet it is one of the most effective forms of pain management known to man — yet at the same time it can and does cause great harm and death in sections of our society.
So where has our system failed or gone wrong?
Prescription opioid and heroin abuse continues to be a matter of great concern in the United States.
According to the National Institute of Drug Abuse, in 2014 more than 47,000 drug overdose deaths occurred in the US, among which there were more than 18,000 deaths from prescription opioid pain reliever overdose and more than 10,000 deaths from heroin-related overdose.
The institute noted that the 2014 data demonstrated that the opioid overdose epidemic “reflected a 15-year increase in overdose deaths involving prescription opioid pain relievers and a recent surge in illicit opioid overdose deaths, driven largely by heroin overdose”, para 446 INCB Report 2016.
Sadly, the scenarios mentioned above are not isolated to North America; it is a growing concern throughout the developed world.
It is widely reported by the INCB that of the seven billion people worldwide only 1.5 billion have access to pain medication. The reasons for this are many and varied but include cost, lack of rule of law, and a lack of trained medical personnel.
“The imbalance in the availability of opioid analgesics is particularly worrying as the latest data shows many of the conditions that require pain management, particularly cancer, are prevalent and increasing in low-income and middle-income countries.
At the same time, in recent years there has been an
increase in the abuse of prescription drugs and related overdose deaths in countries with high per capita levels of consumption of opioid analgesics,” para 9, INCB Report 2015.
It was encouraging to read the March 2 edition of
Medicine Today feature “Clinical care and regulation of opioid use — the Tasmanian model”.
Perhaps a way forward from the opioid overuse/abuse epidemic would be as a starting point adoption of the Tasmanian model.
Supply is not the issue, it is the demand and apparent inappropriate use of prescription opioid drugs in our developed economies that is the major problem.
We need appropriate and robust solutions from all levels of the community, and these solutions must be scientifically based and supported by more effective health care systems.
In particular, we need better information management systems that can measure, monitor and ensure adherence to the desirable care models. Dr Terry J. Hannan is a consultant physician at the Launceston General Hospital. He has worked extensively in palliative care and chronic pain management, is clinical Associate Professor in the School of Human Health Sciences at the University of Tasmania’s Department of Medicine, and visiting Fellow, Centre for Health Informatics, Macquarie University. Mr Keith Rice is chief executive of Poppy Growers Tasmania Inc.